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A Giant Neurovascular Lower Limb Fillet Flap Can Simultaneously Cover Pelvic and Abdominal Defects

Osinga, Rik, MD*; Nowakowski, Andrej, MD, BSc, PhD; Isaak, Andrej, MD; Schaefer, Dirk, J., MD*; Fulco, Ilario, MD*

Plastic and Reconstructive Surgery – Global Open: December 2017 - Volume 5 - Issue 12 - p e1626
doi: 10.1097/GOX.0000000000001626
Case Report
Switzerland
Best Paper

Summary: The first description of simultaneous pelvic and abdominal soft-tissue reconstruction with a giant lower limb fillet flap after hip exarticulation and open abdomen is presented. The unfortunate circumstances of a 67-year-old female patient are described leading to soft-tissue necrosis over a periprosthetic femur fracture and open abdomen after emergency implantation of an aortic bifemoral Y-prosthesis because of thrombotic obliteration of the aortic bifurcation. After removal of the hip prosthesis, the neurovascular pedicled myocutaneous fillet flap of the entire left leg was raised and folded proximally at the level of the exarticulated joint of the hip and set into the pelvic and abdominal defect. A giant pedicled neurovascular myocutaneous fillet flap raised over the entire lower extremity is a safe, effective, durable, and sensation-preserving treatment to reconstruct combined pelvic and abdominal soft-tissue defects.

From the *Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland; Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland; and Vascular Surgery, Department of General Surgery, University Hospital Basel, Basel, Switzerland.

Received for publication September 11, 2017; accepted November 8, 2017.

Presented at the 53rd National Congress of Swiss Plastic Surgery on September 1, 2017 in St. Moritz, Switzerland.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Rik Osinga, MD, Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Spitalstrasse 25, Basel 4031, Switzerland, E-mail: rik.osinga@usb.ch

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects. Fillet flaps can be used to treat traumatic, oncologic, or pressure-induced wounds. The classical fillet flap is defined as an axial-pattern flap harvested from amputated, discarded or otherwise nonfunctioning or nonsalvageable areas of the body that can be used as a pedicled, island, or microvascular free flap, allowing regional or heterotopic defect reconstruction.1 Its advantage is little or no donor-site morbidity, as it serves as “spare part” of otherwise discarded body parts. We present the case of a giant neurovascular pedicled myocutaneous lower limb fillet flap for pelvic and abdominal soft-tissue reconstruction after hip exarticulation and open abdomen. Informed consent was given by the patient.

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PATIENT

A 67-year-old, multimorbid female patient was referred from a secondary hospital with acute thrombotic obliteration of the aortic bifurcation due to heparin-induced thrombocytopenia type 2 9 days after revision surgery of a periprosthetic luxation fracture of the left hip and 16 days after unilateral implantation of a hip prosthesis. An aortic bifemoral Y-prosthesis and a femorofemoral crossover bypass from left to right were implanted and replaced the following day because of recurrent thrombosis. Bilateral fasciotomies of the lower extremities were necessary, and amputation of the right lower leg was inevitable. Abdominal compartment syndrome developed, necrotic intestine had to be removed, and a Hartmann’s procedure followed. The open abdomen was treated with negative-pressure wound therapy. Further soft-tissue necrosis developed over the periprosthetic fracture, eventually leaving the left femur and the femoral stem of the hip prosthesis uncovered (Fig. 1). Distal to the aortic femoral bypass, the left leg was fully perfused with preserved sensibility.

Fig. 1

Fig. 1

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PROCEDURE

With the patient in supine position, all wounds were thoroughly debrided, the components of the total hip prosthesis removed, and the exposed bony pelvis debrided until reaching healthy bleeding bone. Deep bone samples were sent for bacteriological and histological analysis. The iliopsoas tendon was attached to the ramus superior of the pubic bone. The fillet flap was raised with the ventral incision beginning at the distal end of the wound over the lateral left femur, curving laterally of the patella down to approximately 2 cm above the fibular head at which point the incision is brought anterior toward the anterior border of the peroneus longus muscle to preserve the peroneal artery and common peroneal nerve. The incision was then continued caudally to the ankle so gaining sufficient soft tissue for coverage of the pelvic and abdominal defect where a circumferential incision was made. Following the distal ligation of the posterior tibial, peroneal, anterior tibial artery and veins, the distal leg and foot were amputated. The peroneal nerve branches (superficial and deep) and posterior tibial nerves were divided sharply distally and buried in the adjacent musculature to prevent neuroma formation.

Superiorly, after dissection of the remaining quadriceps muscle, the femur and its remaining periosteum were lifted, meticulously protecting the posterior popliteal vessels and the saphenous and sciatic nerve. The tibia was removed after dissecting the posterior tibial artery and nerve bluntly and separating the tibia from its periosteum. The fibular periosteum was incised medially and the fibula stripped, carefully sparing the anterior tibial and peroneal vessels (Fig. 2). The flap was folded proximally at the level of the exarticulated joint of the hip with the hamstring musculature filling the dead space and held by Vicryl 0 sutures. After removal of the remnants of the quadriceps muscle, the fillet flap was set into the defect by suturing the deep fascia to the recipient fascial layer after placement of drains. The dermal and superficial layers were approximated using 2-0 Vicryl and 2-0 Prolene sutures and skin staplers (Fig. 3).

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Minor wound dehiscence occurred laterally after 4 weeks and was treated with negative wound pressure and secondary closure. The remaining fasciotomy of the right upper leg was closed primarily; the right inguinal wound was covered with split-thickness skin graft from the right upper leg. Despite renal failure, diabetes and corticosteroid application due to drug reaction with eosinophilia and systemic symptom2 syndrome, complete and stable wound healing was achieved 4 months after the initial operation (Fig. 4). The patient was consequently mobilized into a chair for several hours a day without development of pressure ulcerations over the flap.

Fig. 4

Fig. 4

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DISCUSSION

Excision of the femur and lower extremity bones with preservation of the soft tissue (ie, fillet) for pressure ulcer reconstruction was initially described in 1956 and named “total thigh flap”.3 More case series followed mainly for pressure ulcer coverage in paraplegic and nonparaplegic patients.4 , 5 The classical fillet flap emerged from the “spare part” concept, using tissues from amputated or otherwise discarded body parts to replace important functional structures.1 However, the fillet flap was never described to simultaneously cover both a pelvic and abdominal soft-tissue defect. We presented the flap elevation technique and coverage of these defects after hip exarticulation and burst abdomen. The advantages of using a neurovascular pedicled myocutaneous fillet flap are (1) the robust vascular supply; (2) also for larger or giant flaps; (3) the possibility of using musculature to fill dead space; and (4) the possibility of having a fully sensate flap. We are convinced that these advantages outweigh the obvious functional, social, and psychological difficulties that accompany the flap described.

In contrast to a free neurovascular fillet flap, the success is dependent neither on the patency of the microvascular anastomosis nor on the process of reinnervation after microsurgical nerve coaptation requiring additional sensory re-education. A theoretical disadvantage includes the possibility of destabilizing the pelvis when sitting, which may lead to a high pressure located over the contralateral Tuber ischiadicum.

In this case, the fillet flap was spared from a damaged limb with considerable soft-tissue damage over an open, periprosthetic fracture of the femur. In view of the multimorbidity of the patient, we chose a 1-step leg-sacrificing procedure over a multistep, perhaps leg-retaining alternative with hip prosthesis removal and necessary free-flap soft-tissue coverage to cure osteomyelitis of the femur. After an interval of usually 3 months, fracture fixation of the femur and reimplantation of a new hip prosthesis would have been necessary. The open abdomen on the other hand would have continued to need temporary closure followed by fascial defect closure as quickly as clinically feasible without increasing intraabdominal pressure, and definitive closure through one of the multiple techniques described.

In summary, a giant pedicled neurovascular myocutaneous fillet flap from the lower extremity is a safe, effective, durable, and sensation-preserving treatment to reconstruct combined pelvic and abdominal soft-tissue defects.

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ACKNOWLEDGMENTS

We thank the nurses and doctors of the Intermediate Care Unit of the University Hospital Basel for their tireless efforts providing maximum care for our patient. Furthermore, the authors thank Charles Rudin, University Hospital Basel, for photography assistance.

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REFERENCES

1. Küntscher MV, Erdmann D, Homann HH, et al. The concept of fillet flaps: classification, indications, and analysis of their clinical value. Plast Reconstr Surg. 2001;108:885–896.
2. Cacoub P, Musette P, Descamps V, et al. The DRESS syndrome: a literature review. Am J Med. 2011;124:588–597.
3. Georgiade N, Pickrell K, Maguire C. Total thigh flaps for extensive decubitus ulcers. Plast Reconstr Surg. 1956;17:220–225.
4. Royer J, Pickrell K, Georgiade N, et al. Total thigh flaps for extensive decubitus ulcers. A 16 year review of 41 total thigh flaps. Plast Reconstr Surg. 1969;44:109–118.
5. McCarthy JE, Rao VK. Systematic review and operative technique of recalcitrant pressure ulcers using a fillet flap technique. Plast Reconstr Surg Glob Open 2016;4:e1001.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.